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Communications to the Editor |

Is the Method of Modified Percutaneous Tracheostomy Without Bronchoscopic Guidance Really Simple and Safe? FREE TO VIEW

Matthias Gründling, MD; Dragan Pavlovic, MD; Sven-Olaf Kuhn, MD; Frank Feyerherd, MD
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University of Greifswald, Greifswald, Germany

Correspondence to: Matthias Gründling, University of Greifs-wald, Department of Anaesthesiology, Fr-Loeffler-Str 23b, Greifs-wald 17487, Germany; e-mail: gruendli@uni-greifswald.de



Chest. 2005;128(5):3774-3775. doi:10.1378/chest.128.5.3774-a
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To the Editor:

Since Ciaglia1introduced for the first time the percutaneous dilatational tracheostomy (PDT) method using various stoma dilators, other newly developed related methods have been accepted for airway management in patients receiving long-term mechanical ventilation. Nevertheless, the techniques do not always include bronchoscopic control, and the advantages and disadvantages of the simultaneous use of bronchoscopy have been extensively discussed.23 An important contribution to that discussion has been a recent article in CHEST (September 2004)4 about modified PDT without bronchoscopic guidance, which we read with great interest. The authors concluded that “modified percutaneous tracheostomy,” a technique that does not use bronchoscopic control, is a simple and safe method if performed by a trained physician who has had some practice in neck surgery. However, we only partially share the authors’ optimism.

During the last 9 years, we have performed > 800 percutaneous tracheotomies using various commercial sets, all with the use of a bronchoscope. We are convinced that a constant visual survey of the inside of the trachea during the entire duration of the PDT procedure offers important advantages.2 A malplacement of the tube is thereby practically excluded, and a tracheal wall injury can either be entirely avoided or recognized early and treated. We think that the originally described techniques of PDT owe their success largely to the later introduction and use of bronchoscopy at different stages of the procedure; as much as the technique permits.2 Those problems with the described method4 mentioned below, which may be linked to the absence of bronchoscopic control, could all be causally interconnected.

Bronchoscopy application permits the precise positioning of the initial needle puncture between the second and third tracheal rings. If a bronchoscope were used, the level of puncture with a needle could be identified without skin incision by simultaneous observation through the bronchoscope and the application of a slight pressure to the skin over the trachea. Without bronchoscopy, the level of the puncture is uncertain, and, as a result, too high a puncture could lead to complications that have been described accompanying high placement of the cannula.56 Too low a puncture may impose a risk of bleeding. If a large thyroidal gland is present, there would be a danger of accidentally cutting across some blood vessels that are positioned beneath, such as the thyroidal arteries, the left brachiocephalic vein, or even the brachiocephalic trunk itself.

With bronchoscopy, not only is the initial placement of the needle fully controlled, but also all steps of the PDT. The permanent observation of the skin surface and, at the same time, the visualization of the inside of the trachea and control of the progress of the tip of the inserted devices (ie, needle, guidewire, and cannula) help to prevent injury, particularly of the membranous tracheal wall. Freedom of movement of those devices introduced into the tracheal lumen is extremely small, and without the use of a bronchoscope the procedure remains largely “blind” and the risk for injury during all stages is high.

In the article under discussion,4 the initial puncture level may have been incorrect; this could have been avoided if bronchoscopy had been used. The authors stated that they performed a midline, 2-cm-long, incision just above the suprasternal notch. Certainly, it is not clear how a palpation by the finger at such a low level (ie, at the sternal notch) could permit identification of the second and third tracheal rings? Such an extremely low point of incision would seldom allow the performance of a tracheal puncture, as described in the article, between the second and third tracheal ring. In Figure 3 of that article, one can even see that the needle is introduced between the fourth and fifth tracheal rings. However, at that level the normal anatomy looks slightly different than the way it is depicted in Figure 3 of the article. The trachea does not follow the frontal plane of the neck, diverging dorsally, so that to approach for dissection of the trachea at that low level has to be deeper, compared to the one that would be performed at the level of the second tracheal ring. We can only speculate that the increased distance between the skin plane and the tracheal lumen at that low level could have been the cause of the finding that one tracheal cannula was too short in the case of a patient undergoing a Griggs tracheostomy that was described in the article.,4

In addition, such a low approach may impose a need for extensive surgical dissection accompanied by the above-mentioned complications. This may have disastrous consequences. Bleeding and local infection may by themselves create conditions, in the latter case, for the occurrence of tracheal stenosis. A generous surgical approach, as required in the absence of any bronchoscopic control, may, in addition, be responsible for a loose or badly secured tracheal cannula. This might be one of the reasons for the displacement of the cannula in the first 48 h that was observed in the three patients in the study.4 When such a deep surgical dissection of the trachea is performed, one should probably not use a commercial and expensive tracheotomy set to perform a “percutaneous” tracheotomy, and should instead complete the operation using a routine surgical procedure.

It may be of lesser importance, but it should be mentioned that the enthusiastic conclusion of the authors that the modified percutaneous tracheostomy without bronchoscopic guidance is the simplest and safest method, may be applied to the Ciaglia “Blue Rhino” method7 only hypothetically since this method was used in only eight patients in the study.

Some drawbacks in the use of bronchoscopy, like carbon dioxide retention, certainly exist, and the use of a bronchoscope would therefore be contraindicated in patients who would not support high CO2 levels, like those with brain injuries. There are, of course, other circumstances in which the use of modified percutaneous tracheostomy without bronchoscopic guidance would probably be the best choice if the bronchoscope were not at hand. In those circumstances, this technique would be much more suitable than the customary PDT without a bronchoscope. There are however important limits of the method described by Paran et al,4 and a general dismissal of the usefulness of bronchoscopy would certainly not be warranted.

Ciaglia, P, Firsching, R, Syniec, C. (1985) Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report.Chest87,715-719
 
Marx, WH, Ciaglia, P, Graniero, KD. Some important details in the technique of percutaneous dilatational tracheostomy via the modified Seldinger technique.Chest1996;110,762-766
 
Reilly, PM, Sing, RF, Giberson, FA, et al Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy.Intensive Care Med1997;23,859-864
 
Paran, H, Butnaru, G, Hass, I, et al Evaluation of a modified percutaneous tracheostomy technique without bronchoscopic guidance.Chest2004;126,868-871
 
Dollner, R, Verch, M, Schweiger, P, et al Laryngotracheoscopic findings in long-term follow-up after Griggs tracheostomy.Chest2002 Jul;122,206-212
 
van Heurn, LW, Theunissen, PH, Ramsay, G, et al Pathologic changes of the trachea after percutaneous dilatational tracheotomy.Chest1996;109,1466-1469
 
Byhahn, C, Lischke, V, Halbig, S, et al Ciaglia blue rhino: a modified technique for percutaneous dilatation tracheostomy. Technique and early clinical results.Anaesthesist2000;49,202-206.
 

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References

Ciaglia, P, Firsching, R, Syniec, C. (1985) Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report.Chest87,715-719
 
Marx, WH, Ciaglia, P, Graniero, KD. Some important details in the technique of percutaneous dilatational tracheostomy via the modified Seldinger technique.Chest1996;110,762-766
 
Reilly, PM, Sing, RF, Giberson, FA, et al Hypercarbia during tracheostomy: a comparison of percutaneous endoscopic, percutaneous Doppler, and standard surgical tracheostomy.Intensive Care Med1997;23,859-864
 
Paran, H, Butnaru, G, Hass, I, et al Evaluation of a modified percutaneous tracheostomy technique without bronchoscopic guidance.Chest2004;126,868-871
 
Dollner, R, Verch, M, Schweiger, P, et al Laryngotracheoscopic findings in long-term follow-up after Griggs tracheostomy.Chest2002 Jul;122,206-212
 
van Heurn, LW, Theunissen, PH, Ramsay, G, et al Pathologic changes of the trachea after percutaneous dilatational tracheotomy.Chest1996;109,1466-1469
 
Byhahn, C, Lischke, V, Halbig, S, et al Ciaglia blue rhino: a modified technique for percutaneous dilatation tracheostomy. Technique and early clinical results.Anaesthesist2000;49,202-206.
 
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